Total subapical mandibular osteotomy to correct class II dento-facial deformity

8/12/2019 Total subapical mandibular osteotomy to correct class II dento-facial deformity

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Official Publication of Orofacial Chronicle , India

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CASE REPORT

Total subapical mandibular osteotomy to correct class

II dento-facial deformity

Munoz R1 ,Golaszewski J2 ,Diaz, A3

1,2,3- Oral and Maxillofacial Surgeon.

Dr ANGEL LARRALDE Carabobo Universitary Hospital, VENEZUELA

ABSTRACT:

Many patients with class II dentofacial deformities, skeletal alterations, where the

jaw may occurs regarding the retruded maxilla or in other cases presenting

anatomical changes. There are many options for treating this type of malocclusion

using orthodontic appliances or orthodontic-surgical procedures. Depending on the

nature of the problem and its severity, the surgical correction of Class II

dentofacial deformities may involve surgery or bimaxillary monomaxilar. This

paper reports a case of class II dentofacial deformity, which was treated by the

technique of subapical osteotomy total, following the completion of presurgical

orthodontics. In this paper we present a female patient aged 24 who presented

Class II dentofacial deformity. Facial analysis showed deficiency third height

lower face, neck, chin line between 42mm approx normal values, the overjet was 6

mm with a marking groove and quantified mentolabial 5mm dental midlines.

Patients in the immediate postoperative period have the ability to open and close

his mouth with mild discomfort and decreased facial edema. After the initial period

of Hypoaesthesia, is associated with a recovery of the sensitivity of the lower lip,

as well as the oral mucosa and gingiva.


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KEYWORDS. Osteotomy, total subapical, overjet, Dentofacial deformities Class

II

Cite this Article: Munoz R,Golaszewski J, Diaz, A:Total subapical mandibular osteotomy

to correct class 2 dento-facial deformity: Journal of Head & Neck physicians and

surgeons Vol 2 Issue 1 2014 : Pg 91-101

INTRODUCTION:

Class II malocclusions are the most frequent of dentofacial deformities seen in

clinical practice, occurring in 13% of the population (Proffit, et al., 1998) Many

patients with class II dentofacial deformities, which may occur retruded jaw in

relationwith to the maxilla or other anatomic abnormalities. There are many

options for treating this type of malocclusion using orthodontic appliances or

orthodontic-surgical procedures (Cassidy et al., 1993). Depending on the nature of

the problem and its severity, the surgical correction of class II dentofacial

deformities may involve surgery monomaxillary or bimaxillary. The sagittal split

osteotomy is the technique used for Excellence (Trauner et al., 1957). Subapical

osteotomy was first described by Hullinhen (Hullihen et al.,1849) . However, this

surgery was limited to the anterior portion only. Hofer 1942 and Kole (1959),

popularized the subapical technique.

Total mandibular alveolar osteotomy was described by Macintoch (1974) for the

correction of apertognathia or anterior open bite. Eliades and Hegdvedt (1996)

reported a case where describe a combination of sagittal split osteotomy with full

subapical osteotomy for correction of Class II malocclusions successful branch2.

Pangrazio-Kulbersh (2001) compared the total subapical osteotomy with bilateral

sagittal split osteotomy for correction of class II dentofacial deformities, showingboth long-term stable results. They refer in their article that the subapical

osteotomy was used in the case where the depth wanted mentolabial improve.

(Boye et al., (2012) described the overall subapical osteotomy technique where

perfom a identification of mental nerve, and they make a careful removal of

cortical bone around the mental foramen with total replacement upwards or


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downwards with respect to the channel. Among the disadvantages described for

full subapical osteotomy included the time required to perform the surgery

meticulously avoiding mental nerve damage, loss of tooth vitality, loss of teeth or

alveolar necrosis. This article report a case of class II dentofacial deformity, which

had deep sulcus mentolabial and projected chins, which were treated by completesubapical osteotomy technique with a modification of the original technique (Fig

1).

SURGICAL TECHNIQUE:

After nasotracheal intubation was performed aseptic and antiseptic techniques,

local anesthetic infiltrated Lidocaine 2% with Epinephrine 1:80,000 in the

mandibular region. A circunvestibular incision was made from canine to canine,

and lower vestibular incision in the molar area taking into account the damage to

the mental nerve and the minimum subperiosteal dissection is necessary in order

to perform the operation using mucoperiosteal tunnel. Performing the subsequent

vertical line marking on the third molar region and anterior midline level quantized

with respect to the height of the mental nerve, obtained in the prediction surgical

panoramic radiograph and lateral cephalic radiographic. Then proceed to make the

retro molar vertical osteotomy with reciprocating saw avoiding injuring the lingual

mucosa. Then proceeds to perform horizontal osteotomy from the retro molar

mucoperiosteal tunnel through to the anterior midline of the apexes 5mm dentalconsidering avoid injury to the oral mucosa. Likewise, it proceeds to the

contralateral side for dentoalveolar subapical block release.

When the dentoalveolar segment is completely separated from the base portion, we

proceeds to move it, and is reset to the pre-planned position, the entire

dentoalveolar segment is now stabilized and fixed by osteosynthesis plates 2.0

system and monocortical screws, both in the zone anterior and posterior. Thebuccal mucosa is then sutured with absorbable suture (fig 2).

CASE REPORT:

Female patient is 24 years of age who presented class II dentofacial deformity (Fig

3). Facial analysis showed deficiency lower third height facial chin line between


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normal neck approx 42mm, 6mm its overjet was marked with a groove and

quantified mentolabial sulcus in 5mm; dental midlines facial were aligned, she had

an adequate soft pogonion projection with an aesthetically chin. Subsequent

evaluation is requested preoperative clinical examination, conventional

radiographs (lateral cephalic Rx, Rx panoramic, skull PA Rx)( Fig 4), modelstudies were made.Then he proceeded to perform preoperative cephalometric

tracings and surgical prediction (Protocol Bell, Obwegeser, Epker, Wolford) and

model surgery for surgical planning.

Fig 1. Total subapical osteotomy Muoz, Golaszewski, Diaz (2013)

(a)


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(b)

(c)

(d)

Fig 2. Intraoperative clinical fotographs. Subperiosteal dissection (a). references lines for

osteotomies (b). frontal view of the osteotomies (c). clinical fotographs of rigid fixation (d)


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(a) (b) (c)Fig 3. Clinical phothographs frontal view (a), lateral view (b) presurgical intraoral view (c)

(a) (b)


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Fig 4. Preoperative conventional radiographs. Panoramic (a). Lateral cephalogram (b)

(a) (b) (c)

Fig 5. Preoperative fotographs. Frontal (a) and lateral (b) views. Postoperative intraoral view (c)

A


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B

Fig 6. Postoperative conventional radiographs. Panoramic (a) lateral cephalogram (b)

After performing the preoperative was scheduled make subapical osteotomy

technique for advancing Total 6mm. It was made to order by the case Orthodontist

for placement of surgical pins and proceed with the surgery. During surgery

proceeded to the performance of the technique described above.

DISCUSSION:

Today subapical osteotomy has been reported in the literature, most of these

reports are limited to surgical procedures to the anterior portion, while the

subapical osteotomy total reasonable surgical alternative for the correction of

certain class II dentofacial deformities, currently has very few reports (Dietz et al.,

1977) One of the reasons for the popularity of poor technique Mandibular basal

osteotomy may be due to the intricacy (Boye, 2012) implies an increase of between

1.5 to 2 times the time taken in performing a bilateral sagittal split osteotomy

branch. Surgery in our report did not imply an increase in surgical time

development of a conventional act .From the perspective of patients the technique

has a higher number of advantages. The pain and dysphagia associated with

bilateral sagittal split osteotomy branch is lower in the basal mandibular osteotomy

technique (Murray et al., 1980)


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Patients in the immediate postoperative period have the ability to open and close

your mouth with mild discomfort and decreased facial edema. Subsequent to the

initial period Hypoaesthesia, recovery is associated sensitivity of the lower lip aswell as the oral mucosa and attached gingiva. It must be handled with caution to

avoid injury to the apices of the teeth and the inferior alveolar nerve, which can

lead to devitalization of dental unit.

We feel that the total subapical osteotomy was indicated because it preserved the

integrity of the complete lower dental arch and also allowed antero-posterior and

vertical correction of the malocclusion resulting in an excellent aesthetic and

functional result. We believe it is a technique that should be used by trained

surgeons, because the success of the technique is based on the cautious and

meticulous handling of soft tissue as well as the appreciation of the anatomical

structures of the area. In addition to respecting the basic principles of surgery

avoiding excessive subperiosteal dissection when performing osteotomies.

CONCLUSION:

This technique should be used by trained surgeons, because the success of the

technique is based on caution and meticulous management of soft tissue as well as

the appreciation of the anatomical structures of the area. In addition to respecting

the basic principles of surgery avoiding excessive periosteum when performing the

osteotomies. Due to the sensitivity of the performance of this technique and

possible complications is considered important the choice of patients under the

indications of this technique. This technique should be considered in handling

potential surgical class II dentofacial deformities, due to its excellent postoperative

cosmetic result.


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REFERENCES:

1. Proffit WR, Fields Jr HW, Moray LJ: Prevalence of malocclusion and orthodontic treatmentneed in the United States: estimates from the NHANES III survey. Int J Adult Orthodon

Orthognath Surg 13: 97e106, 1998

2. Cassidy Jr DW, Herbosa EG, Rotskoff KS, Johnston Jr LE: A comparison of surgery andorthodontics in borderline adults with class II, division malocclusions. Am J Orthod

Dentofacial Orthop 104: 455e470, 1993

3. Trauner R, Obwegeser H: The surgical correction of mandibular prognathism and retrognathiawith consideration of genioplasty. I. Surgical procedures to correct mandibularprognathism

and reshaping of the chin. Oral Surg Oral Med Oral Pathol 10:677e689, 1957

4. Hullihen SP: Case of elongation of the underjaw and distortion of the face and neck, causedby a burn, successfully treated. Am J Dent Sci 9:157, 1849

5. Hofer O: Operation der prognathie und mikrogenie. Dtsch Zahn Mund Kieferh 9:121, 19426. Kole H: Surgical operations on the alveolar ridge to correct occlusal abnormalities.Oral Surg

Oral Med Oral Pathol 12: 277e288, 1959

7. MacIntosh RB: Total mandibular alveolar osteotomy. Encouraging experiences with aninfrequently indicated procedure. J Maxillofac Surg 2: 210e218, 1974

8. Eliades T, Hegdvedt AK: Orthodontic-surgical correction of a class II, division 2malocclusion. Am J Orthod Dentofacial Orthop 110: 351e357, 1996

9. Pangrazio-Kulbersh V, Berger JL, Kaczynski R: Stability of skeletal class II correction with 2surgical techniques: the sagittal split ramus osteotomy accxcxnd the total mandibular

subapical alveolar osteotomy. Am J Orthod Dentofacial Orthop 120: 134e143, 2001

10.Boye et al. Total subapical mandibular osteotomy to correct class 2 divisiondento-facial deformity. Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 238e242

11.Dietz VS, Gianelly AA, Booth DF: Surgical orthodontics in the treatment of a class II,division 2 malocclusion: a case report. Am J Orthod 71: 309e316, 1977

12.Murray RB: Mandibular sagittal subapical osteotomy: a case study. Am J Orthod 77:469e485,1980

Acknowledgement-None

Source of Funding-Nil

Conflict of Interest-None Declared


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Total subapical mandibular osteotomy to correct class II dento-facial deformity